Reflecting on Health Reform: Time to Move On?

For the last four years, politicians, policymakers, and the media have focused almost obsessively on the coverage provisions of the Affordable Care Act (ACA). The fundamental question has been whether the law would survive or be repealed, and its coverage provisions—the creation of new individual and small-business marketplaces and its Medicaid expansions—have been at the heart of this question. If large numbers of Americans gained valued health care coverage through the law, its repeal or replacement would be enormously difficult.

The launch of the individual marketplaces was encouraging to opponents of the ACA because of the initial, nearly disastrous failures of the federal and many state websites meant to facilitate enrollment. In addition, some state governments not only refused to expand Medicaid or launch their own websites, but sought actively to discourage eligible citizens from enrolling. Then came the cancellation by insurance companies of individual policies that failed to meet the ACA’s minimum standards for non-grandfathered plans. These and other less publicized twists, turns, and glitches made it seem conceivable that Congress might actually repeal the Affordable Care Act, just as it repealed the extension of catastrophic coverage to Medicare beneficiaries in 1989.

Offstage, however, a different story was unfolding. The federal website got fixed. State websites in places like California, New York, Connecticut, Rhode Island, and Kentucky worked well. Millions of Americans were found eligible for Medicaid or the Children’s Health Insurance Program in states that expanded eligibility. More young people got coverage under their parents’ insurance policies.

As of this writing, more than 18 million Americans have been touched by the coverage provisions of the law. This compares with perhaps a few million who may have been adversely affected by policy cancellations, and many of these have found or will find comparable or better coverage through now-functioning individual marketplaces. Whether or not the final tally of enrollees in the individual marketplaces on March 31 reached some magical target hardly seems to matter. The numbers of ACA beneficiaries will continue to swell over the months and years to come as another open enrollment period commences in November 2014, and as Medicaid enrollment continues.

The next Congress may be controlled by opponents of the ACA, but they will face daunting facts on the ground. It seems likely that by January 2015, when the new Congress convenes, somewhere between 20 and 25 million Americans will be insured under provisions of the Affordable Care Act, nearly the population of Texas. Many millions more will enjoy protections against arbitrary termination or denial of private coverage. As recent reports have begun to emphasize, citizens in some states are benefiting much more than others from coverage extensions. But that does not change the fundamental fact that the political cost of taking away—or seeming to take away—these benefits from tens of millions of citizens—wherever they live—will be formidable.

On top of this, President Obama will remain in the White House, veto pen in hand. Unless one of the remaining constitutional challenges to the law succeeds, the ACA will stay on the books until a new president takes the oath of office in January 2017. By that time, who knows what the enrollment total will be?

The prospects of repealing the ACA seem minimal. But it does have flaws that need fixing. New insurance plans will have problems, such as restrictions on health care provider networks. Coverage may be insufficient for people who buy plans with very high deductibles and copayments. Beyond this, our health care delivery system is still broken: inefficient, overly costly, and harmful to millions of Americans. And this has serious implications for the affordability of private and public health care coverage, regardless of how it is obtained.

Mission

The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.